Devices for treating paravalvular leakage and associated methods

ABSTRACT

An elongate member has a longitudinal axis, and has an elongated configuration in which the elongate member defines (i) a first portion that defines a first-portion folding line, substantially orthogonal to the longitudinal axis, (ii) a second portion that defines a second-portion folding line, substantially parallel to the first-portion folding line, and (iii) an oblique folding line, longitudinally between the first portion and the second portion. The oblique folding line is nonparallel and nonorthogonal to the longitudinal axis. A tensioning member weaves longitudinally along the elongate member such that applying tension to the tensioning member transitions the elongate member toward a folded configuration by folding (i) the first and second portions about their respective folding lines, and (ii) the elongate member about the oblique folding line in a manner that positions the first-portion folding line nonparallel to the second-portion folding line.

CROSS-REFERENCE TO RELATED APPLICATION

This application is a Continuation of U.S. patent application Ser. No.16/249,470, filed Jan. 16, 2019, which is a Continuation of U.S. patentapplication Ser. No. 15/061,549, filed Mar. 4, 2016, which is based onand claims priority to U.S. Provisional Patent Application No.62/128,997, filed Mar. 5, 2015, all of which are incorporated byreference, as if expressly set forth in their respective entiretiesherein.

BACKGROUND

Paravalvular leakage is a complication associated with the implantationof a prosthetic valve. It may occur both in traditional surgical orminimally invasive transcatheter approaches. FIG. 1 illustrates anartificial valve 1600 that may include, for example, a multi-leafletstructure 1602 and that may be implemented in an appropriate manner aswill be appreciated by those of ordinary skill in the art. Additionally,a small opening or space 1604 between the heart 1606 and the valve 1600is shown as may occur in some instances of valve replacement. Thisopening or space 1604 results in undesired leaking during pumping of theheart and is termed a valvular or paravalvular leak.

Accordingly, devices and methods are needed for correcting paravalvularleakage after implantation of a stented prosthetic valve.

BRIEF SUMMARY OF THE INVENTION

One aspect of the present teachings includes an anchor for treating aparavalvular leakage. In various embodiments, the anchor includes atleast one elongate anchor member. In some embodiments, the anchorincludes one elongate anchor member. In some embodiments, the anchorincludes two elongate anchor members. In yet other embodiments, theanchor includes three or more elongate anchor members. In certainembodiments, the two, three, or more elongate anchor members are made ofa same material. In certain other embodiments, the two, three, or moreelongate anchor members are made of different materials.

In some embodiments, the anchor has an elongate configuration where theelongate anchor member is relaxed and extended. In some embodiments, theanchor has a shortened configuration when the elongate anchor member(s)is folded or otherwise shortened. In certain embodiments, the anchor isin its shortened configuration when deployed and/or secured.

According to various embodiments of the present teachings, the elongateanchor member is made of a flexible material. In some embodiments, theflexible material is a surgical grade fabric. The elongate anchor membermay also take various forms such as woven or nonwoven fabrics, polymers,metals, other suitable materials, or combinations thereof. For example,the surgical grade fabric used in various embodiments of the presentteachings can be constructed from a polyester, such as Dacron®, RTM,PTFE, UHMPE, HDPE, polypropylene, polysulfone, or other biocompatibleplastic.

In various embodiments, the elongate anchor member causes a tissueresponse, for example, tissue growth. In some embodiments, the surfacefinish of the anchor member is textured to induce tissue response andtissue in-growth for improved stabilization. In other embodiments, theanchor member comprises porous materials to promote tissue in-growth.

In various embodiments, one or more of the edges and/or other portionsof the anchor member are modified, for example, to prevent from fraying.In some embodiments, one or more of the edges or other portions of theanchor member are coated with a material that locks the fibers in place.Other methods can also be used to lock the fibers at one or more edgesof the anchor member in place.

In various embodiments, the anchor includes at least one tensioningmember. In some embodiments, the tensioning member causes both ends ofthe elongate anchor member to move towards each other. This motion cancreate a shortened distal portion and/or a shortened proximal portion.In certain embodiments, doing so secures the paravalvular leakagebetween the distal and the proximal portions of the elongate anchormember.

In embodiments where an anchor of the present teachings includes twoelongate anchor members, the tensioning member causes at least one ofthe two elongate anchor members to move towards the other elongateanchor member. In certain embodiments, the tensioning member causes bothof the elongate anchor members to move towards each other. Inembodiments where an anchor of the present teachings includes three ormore elongate anchor members, the tensioning member causes at least oneof the three or more elongate anchor members to move towards anotherelongate anchor member. In certain embodiments, the tensioning membercauses all of the three or more elongate anchor members to move towardsone another. This motion can create shorten elongate anchor members. Incertain other embodiments, doing so secures the paravalvular leakagebetween two of the elongate anchor members.

According to various embodiments of the present teachings, thetensioning member is in the form of a suture, as defined herein. It willbe appreciated that the tensioning member may take forms other than asuture, such as any other small-diameter members having a suitabletensile strength for the intended anchoring use.

In various embodiments, one or both of the tensioning member and theelongate anchor member are made of a resorbable polymer. In someembodiments, such a resorbable polymer is polyactic acid, polyglycolicacid, polycaprolactone, or a combination thereof. Other resorbablepolymers that are known to those skilled in the art can also be usedwithout undue experimentation and thus are within the scope of thepresent teachings. In various embodiments, the material that is used tomake the anchor, i.e., the elongate anchor member(s), the tensioningmember, or both, is multilayered. In some embodiments, the materialincludes a coating of resorbable polymer. In other some embodiments, thematerial includes a semipermeable polymer that optionally is impregnatedwith one or more of the compounds discussed herein. In certainembodiments, the one or more compounds is released in a controlledmanner.

In various embodiments, the anchor, including the elongate anchormember(s), the tensioning member, or both, includes one or morecompounds that address issues associated with the product performance.For example, one or more compounds can be embedded in the anchor member.In certain embodiments, the one or more compounds are released over timeafter implantation. These compounds can reduce calcification, proteindeposition, thrombus formation, or a combination of some or all of theseconditions. The one or more compounds can also be used to stimulate abiological response, for example, to induce tissue in-growth. In someembodiments, the compound is an anti-inflammatory agent. In someembodiments, the compound reduces tissue proliferation adjacent to thedevice. One with ordinary skill in the art would understand thatnumerous agents are available for the above applications and can selectsuch an agent without undue experimentation for each of theapplications. As such, anchors having one or more of the numerous agentsare within the scope of the present teachings.

In various embodiments, the tensioning member extends through openingsalong the elongate anchor member as described herein such thattightening the tensioning member will cause the elongate anchor memberto fold. Although certain examples of anchor deployment are describedherein, one with ordinary skill in the art would appreciate thatdeployment of the anchor may take on various forms due to the flexiblenature of the anchor member, especially when a highly flexible fabric orother materials is used. For example, a fabric material or othersimilarly flexible materials may be folded or otherwise deformed duringa deployment to a leakage site.

Another aspect of the present teachings includes methods of treating aparavalvular leakage. In various embodiments, the method includesproviding an anchor as described herein, positioning the anchor througha paravalvular leakage, deploying the anchor where at least a part ofthe distal portion of the elongate anchor member is on one side of theparavalvular leakage. In various embodiments, the method includesapplying tension to the tensioning member so that at least a part of thedistal portion of the elongate anchor member transitions from theelongate configuration to the shortened configuration. In variousembodiments, the method includes deploying the anchor wherein at least apart of the proximal portion of the elongate anchor member is on theother side of the paravalvular leakage. In various embodiments, themethod includes applying tension to the tensioning member so that atleast a part of the proximal portion of the elongate anchor membertransitions from the elongate configuration to the shortenedconfiguration.

In various embodiments, the method includes providing an anchor asdescribed herein, positioning the anchor through a paravalvular leakage,deploying the anchor where at least a part of a first elongate anchormember is on one side of the paravalvular leakage. In variousembodiments, the method includes applying tension to the tensioningmember so that at least a part of the first elongate anchor membertransitions from the elongate configuration to the shortenedconfiguration. In various embodiments, the method includes deploying theanchor wherein at least a part of a second elongate anchor member is onthe other side of the paravalvular leakage. In various embodiments, themethod includes applying tension to the tensioning member so that atleast a part of the second elongate anchor member transitions from theelongate configuration to the shortened configuration. And in theseembodiments, the anchor used in repairing a paravalvular leakage caninclude two or more elongate anchor members and a tensioning member canpass through one, two, or more of the elongate anchor members.

In various embodiments, anchors of the present teachings are usedpercutaneously. For example, the anchors are delivered percutaneously.In other embodiments, anchors of the present teachings are used inminimally invasive surgeries. In yet other embodiments, anchors of thepresent teachings are used in open-heart surgeries.

In various embodiments, the method includes introducing a catheterapproximately at the paravalvular leakage site. In some embodiments, themethod includes withdrawing the catheter to deploy the anchor where atleast a part of the distal portion of the elongate anchor member is onone side of the paravalvular leakage. In some embodiments, the methodincludes withdrawing the catheter to deploy the anchor wherein at leasta part of the proximal portion of the elongate anchor member is on theother side of the paravalvular leakage. In some embodiments, the methodincludes withdrawing the catheter to deploy the anchor where at least apart of a first elongate anchor member is on one side of theparavalvular leakage. In some embodiments, the method includeswithdrawing the catheter to deploy the anchor wherein at least a part ofa second elongate anchor member is on the other side of the paravalvularleakage.

In various embodiments, a clinician deploys a plurality of anchors in aparavalvular leakage, when necessary and practical.

In various embodiments, upon deployment, at least half number of thefolds is distal to the paravalvular leakage and the rest of the foldsare proximal to the paravalvular leakage. In other embodiments, upondeployment, less than half of the folds are distal to the paravalvularleakage and the rest of the folds are proximal to the paravalvularleakage. In yet other embodiments, upon deployment, more than half ofthe folds are distal to the paravalvular leakage and the rest of thefolds are proximal to the paravalvular leakage.

In various embodiments, upon deployment, at least some of the folds isdistal to the paravalvular leakage. In various embodiments, upondeployment, at least some of the folds are proximal to the paravalvularleakage. In other embodiments, upon deployment, less than half of thefolds are distal to the paravalvular leakage. In other embodiments, upondeployment, less than half of the folds are proximal to the paravalvularleakage. In yet other embodiments, upon deployment, more than half ofthe folds are distal to the paravalvular leakage. In yet otherembodiments, upon deployment, more than half of the folds are proximalto the paravalvular leakage.

In various embodiments, upon deployment, at least one of the folds is inthe paravalvular leakage. In some embodiments, upon deployment, at leastsome of the folds are distal to the paravalvular leakage and at leastone of the folds is in the paravalvular leakage. In some embodiments, atleast some of the folds are proximal to the paravalvular leakage and atleast one of the folds is in the paravalvular leakage. In certainembodiments, upon deployment, at least some of the folds are distal tothe paravalvular leakage, at least one of the folds is in theparavalvular leakage, and at least some of the folds are proximal to theparavalvular leakage.

In various embodiments, upon deployment, at least a part of a firstanchor member is distal to the paravalvular leakage. In variousembodiments, upon deployment, at least a part of a second anchor memberis proximal to the paravalvular leakage. In various embodiments, upondeployment, at least a part of an anchor member is in the paravalvularleakage. In some embodiments, upon deployment, at least a part of afirst anchor member is distal to the paravalvular leakage and at least apart of a second anchor member is proximal to the paravalvular leakage.In certain embodiments, upon deployment, at least a part of a firstanchor member is distal to the paravalvular leakage, at least a part ofa second anchor member is proximal to the paravalvular leakage, and atleast a part of a third anchor member is in the paravalvular leakage.

In various embodiments, the elongate anchor member also includes amarker. The marker can be in the form of threads, beads, or other forms.Without limiting the scope of the present teachings, the marker allowsthe anchor member to be visualized by using a radiographic imagingequipment using x-ray, magnetic resonance, ultrasound, fluoroscopic, orother visualization techniques. In some embodiments, markers areattached to the anchor member. For example, the markers can be wrapped,laminated, and/or bonded through a welding process. An adhesive such ascyanoacrylate or other adhesives known to those skilled in the art canalso be used to attach a marker to the anchor member.

In some embodiments, the marker is a radiopaque marker. In certainembodiments, the radiopaque marker is made of titanium, tungsten,platinum, iridium, gold, an alloy of any of these materials, or acomposite having any of the above materials. Other materials that areknown to those skilled in the art can also be used.

In some embodiments, the marker is a paramagnetic marker. In certainembodiments, the paramagnetic marker is made of a material containinggadolinium, iron, platinum, manganese, cobalt, fluorine, or otherparamagnetic materials. In yet other embodiments, the markers eachcomprises other MR visible materials that are known to those skilled inthe arts.

In some embodiments, the marker is an echogenic marker. In certainembodiments, the echogenic marker is made of a material that is capableof reflecting increased ultrasound waves. Some echogenic materials aredescribed herein elsewhere.

In various embodiments, the marker protrudes out of or is flush with theanchor. In various embodiments, the markers are arranged on the implantin a pattern.

In various embodiments, the anchor or a component thereof is treated sothat the anchor or a part thereof is visible under a visualizationtechnique. In some embodiments, the visualization technique is based onultrasound. For example, the visualization technique isechocardiography. In some embodiments, an elongate anchor member of thepresent teachings is treated so that it is visible in a visualizationtechnique. In certain embodiments, a part of the elongate anchor memberis treated so that it is visible in a visualization technique. In someembodiments, a marker of the present teachings is treated so that it isvisible in a visualization technique. In some embodiments, the treatmentis performed on a surface of an anchor or a component thereof. Incertain embodiments, a surface of at least a part of the elongate anchormember is treated so that the elongate anchor member is visible in avisualization technique. In certain embodiments, a surface of at least apart of the marker is treated so that the marker is visible in avisualization technique.

In various embodiments, the treatment is performed with an echogenicmaterial. For example, the material can contain fluorine element. Insome embodiments, the material includes a perfluoro compound. In certainembodiments, the material includes perflutren. In certain embodiments,the material includes perflexane. In certain embodiments, the materialincludes sulfur hexafluoride. In other embodiments, the materialincludes another echogenic material known to persons with ordinary skillin the art.

In various embodiments, the method includes locating a paravalvularleakage. For example, a paravalvular leakage can be detected and/orlocated by using echocardiography, computed tomography (CT), or cardiacmagnetic resonance. In some embodiments, the method includes locating aparavalvular leakage by using echocardiography.

Yet another aspect of the present teachings includes a device used totreat a paravalvular leakage. In various embodiments, the deviceincludes a catheter and an anchor as described herein. In someembodiments, the catheter includes a distal end and a lumen having anopening at the distal end. In some embodiments, the anchor is providedat least partially in the lumen.

BRIEF DESCRIPTION OF DRAWINGS

Without wishing to narrow the scope of the enclosed claims, the presentteachings may best be understood by reference to the followingdescription taken in conjunction with the accompanying drawings inwhich:

FIG. 1 shows an artificial valve implanted into a heart having aparavalvular leakage,

FIG. 2 is a perspective view of an exemplary anchor in accordance withthe present teachings,

FIG. 3A is a side view of an anchor positioned in a paravalvular leakagein accordance with some embodiments of the present teachings,

FIG. 3B is a side view similar to FIG. 3A, but illustrating the distalportion of the exemplary anchor being moved toward the paravalvularleakage,

FIG. 3C is a side view similar to FIG. 3B, but showing the distalportion of the exemplary anchor fully compressed and engaged against theparavalvular leakage,

FIG. 3D is a side view similar to FIG. 3C but illustrating the proximalportion of the exemplary anchor being moved toward the paravalvularleakage,

FIG. 3E illustrates the proximal and distal portions of the exemplaryanchor fully compressed against opposite sides of the paravalvularleakage,

FIG. 3F is an enlarged cross sectional view of an exemplary anchor fullydeployed and fastened with a paravalvular leakage between proximal anddistal anchor portions,

FIG. 3G is a side view of an anchor positioned in a paravalvular leakagein accordance with some embodiments of the present teachings,

FIG. 3H is a side view similar to FIG. 3A, but illustrating the distalportion of the exemplary anchor being moved toward the paravalvularleakage,

FIG. 3I is a side view similar to FIG. 3B, but showing the distalportion of the exemplary anchor fully compressed and engaged against theparavalvular leakage,

FIG. 3J is a side view similar to FIG. 3C but illustrating the proximalportion of the exemplary anchor being moved toward the paravalvularleakage,

FIG. 3K is a side view similar to FIG. 3C but illustrating the proximalportion of the exemplary anchor being moved toward the paravalvularleakage,

FIG. 3L is an enlarged cross sectional view of an exemplary anchor fullydeployed and fastened with a paravalvular leakage between proximal anddistal anchor portions,

FIG. 4 is a side elevation view of an exemplary anchor in accordancewith some embodiments of the present teachings,

FIGS. 5A-5D are respective side views illustrating a sequence of stepsused for securing the anchor to a paravalvular leakage in accordancewith some embodiments of the present teachings,

FIG. 5E is a view similar to FIG. 5D, but illustrating an alternativetip and tensioning member arrangement in accordance with someembodiments of the present teachings,

FIG. 6A is a front view of the elongate anchor member of an anchor inaccordance with some embodiments of the present teachings,

FIG. 6B is a front elevation view similar to FIG. 6A, but illustratingradiopaque markers in accordance with some embodiments of the presentteachings,

FIG. 6C is a front elevation view of an alternative elongate anchormember having a varying width along its length in accordance with someembodiments of the present teachings,

FIG. 6D is a side elevation view of another alternative elongate anchormember utilizing more rigid fold sections separated by living hinges inaccordance with some embodiments of the present teachings,

FIG. 7A is a perspective view of an anchor in accordance with someembodiments of the present teachings,

FIG. 7B is a perspective view of an anchor in accordance with someembodiments of the present teachings,

FIG. 7C is a perspective view of an anchor in accordance with someembodiments of the present teachings,

FIG. 8 is a perspective view of an anchor in accordance with someembodiments of the present teachings,

FIG. 9 is a perspective view of an anchor in accordance with someembodiments of the present teachings,

FIG. 10A is a perspective view of an anchor in accordance with someembodiments of the present teachings,

FIG. 10B is a side elevation view of the anchor in FIG. 10A,

FIG. 11 is a perspective view of an exemplary anchor deployed across aparavalvular leakage in accordance with the present teachings,

FIG. 12A is a perspective view of an anchor in accordance with someembodiments of the present teachings,

FIG. 12B is a cross-sectional view of an anchor deployed across aparavalvular leakage in accordance with some embodiments of the presentteachings,

FIG. 12C is a side elevation view of the anchor of FIGS. 12A-12B, and

FIG. 12D is top plan view of the anchor of FIGS. 12A-12B.

DETAILED DESCRIPTION

Certain specific details are set forth in the following description andFigures to provide an understanding of various embodiments of thepresent teachings. Those of ordinary skill in the relevant art willunderstand that various features of the present teachings may be usedalone or in numerous combinations depending on the needs and preferencesof the user. Those skilled in the art can also practice otherembodiments of the present teachings without one or more of the detailsdescribed below. Thus, it is not the intention of the present teachingsto restrict or in any way limit the scope of the appended claims to suchdetails. While various processes are described with reference to stepsand sequences in the following disclosure, the steps and sequences ofsteps should not be taken as required to practice all embodiments of thepresent teachings.

As used herein, the term “proximal” means closest to the operator (lessinto the body) and “distal” means furthest from the operator (furtherinto the body). In positioning a medical device from a downstream accesspoint, distal is more upstream and proximal is more downstream.

As used herein, the term “tensioning member” means a member which cantake forms of a suture, cable, wire, or any other small diameter,flexible, semi-rigid or rigid material having a suitable tensilestrength for the intended use. In addition, as used herein, the term“wire” can be a strand, a cord, a fiber, a yarn, a filament, a cable, athread, or the like, and these terms may be used interchangeably.

The term “suture” used herein can be a strand, a wire, a cord, a fiber,a yarn, a filament, a cable, a thread, or the like, and these terms maybe used interchangeably.

Unless otherwise specified, all numbers expressing quantities,measurements, and other properties or parameters used in thespecification and claims are to be understood as being modified in allinstances by the term “about.” Accordingly, unless otherwise indicated,it should be understood that the numerical parameters set forth in thefollowing specification and attached claims are approximations. At thevery least, and not as an attempt to limit the application of thedoctrine of equivalents to the scope of the claims, numerical parametersshould be read in light of the number of reported significant digits andthe application of ordinary rounding techniques.

Unless otherwise defined, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which these present teachings belong. Methods and materialssimilar or equivalent to those described herein can be used in thepractice or testing of the present teachings. In case of conflict, thepatent specification, including definitions, will control. In addition,the materials, methods, and examples are illustrative only and notintended to be limiting.

It will be appreciated that like reference numerals are used herein torefer to like elements in all embodiments and reference numerals withprime marks (′) or double prime marks (″) refer to like elements thathave been modified in a manner as described herein or otherwise shown inthe associated Figure.

Referring first to FIG. 2, an anchor 10 constructed in accordance withsome embodiments of the present teachings generally includes atensioning member 12, such as a suture, extending through spaced apartpoints along an elongate anchor member 14 of flexible material, such asa surgical grade fabric. It will be appreciated that the tensioningmember 12 may take other forms other than suture material, such as cableor any other small diameter member having a high enough tensile strengthfor the intended use. The elongate anchor member 14 may also takevarious forms such as woven or nonwoven fabrics, polymers, metals, orother suitable materials or combinations of materials. One or moreseparate pledgets or other securement members (not shown) may be used inconjunction with the elongate anchor member 14 for added securementand/or concealing the elongate anchor member 14 and, for example,thereby inhibiting blood clotting within or adjacent to the folds thatwill be formed in the elongate anchor member 14.

A woven or nonwoven material may contain additional materials, such asthreads, beads or other elements that cause at least portions of theelongate anchor member 14 to be radiopaque. Currently, a surgical gradefabric constructed from polyester, such as Dacron®, is contemplated foruse in constructing the elongate anchor member 14. One of many possiblealternative materials for use in constructing the elongate anchor member14 is polytetrafluoroethylene (PTFE). Anchor 10 may be partly or whollyformed from materials that are absorbed into the patient's tissue overtime, depending on the intended use. The edges and/or other portions ofthe elongate anchor member 14 may be suitably modified to preventfraying, such as by being coated with a material that locks the fibersin place, or otherwise modified in a manner that locks the fibers atleast at the edges of the elongate anchor member 14 in place.

The suture 12 may extend from a proximal portion 14 a of the elongateanchor member 14 to a distal end portion 14 b and then loop back throughspaced apart points of the elongate anchor member 14 to the proximalportion 14 a where a knot 16 or other stop member is located. As willbecome apparent, the suture 12 extends through spaced apart locationsalong the elongate anchor member 14 such that tensioning of the suture12 or other tensioning member will cause the elongate anchor member 14to form folded portions 14 c when the tensioning member 12 is placedunder tension or pulled. Thus, the elongate anchor member 14 isactivated in this manner between essentially an elongate configuration,such as shown in FIG. 2, and a shortened configuration, such as a foldedor otherwise shortened configuration having an expanded width in atleast one dimension as compared to the elongate configuration. It willbe appreciated that the deployment orientation may take on various formsdue to the flexible nature of the elongate anchor member 14, especiallywhen using a highly flexible fabric or other material. For example, afabric material or other similarly flexible materials may be folded orotherwise deformed for carrying purposes within a catheter and/or duringdeployment to a paravalvular leakage site and then suitably activated atthe leakage site.

More specifically referring to FIGS. 3A-3E, the elongate anchor member14 and attached suture 12 are initially inserted through a paravalvularleakage site 20 as generally shown in FIG. 3A. One end or portion 12 aof the suture 12 is then pulled and thereby placed under tension. Itwill be appreciated that, for catheter-based procedures, suture portion12 a may extend to a location outside the patient's body for pulling ortensioning, or it may be grasped by a suitable mechanism within thecatheter and pulled or tensioned. Pulling suture portion 12 a mayinitially draw the distal portion 14 b of the elongate anchor member 14toward the paravalvular leakage site 20 as shown in FIG. 3B. Once thedistal portion 14 b is compressed against the leakage site 20, theproximal portion 14 a begins to be drawn and compressed against aproximal side of the paravalvular leakage site 20 as shown in FIGS.3C-3E. This occurs because end 12 a of the suture 12 is being pulleddownwardly (as viewed for purposes of discussion in FIGS. 3C-3E) and,since the suture 12 is looped in a reverse direction through distal endportion 14 b of the elongate anchor member 14, the knot 16 at the end ofthe suture 12 moves upwardly and brings the proximal portion 14 a of theelongate anchor member 14 with it. In this manner, the proximal portion14 a of the elongate anchor member 14 is being folded and drawn alongthe suture 12 toward the paravalvular leakage 20 and then firmlycompressed against the proximal side of the paravalvular leakage 20 asshown in FIG. 3E. As further shown in FIG. 3F, a suitable lockerelement, such as a crimp member 22, a knot or other element may be usedto maintain the suture 12 and elongate anchor member 14 in the positionsshown in FIG. 3F securely anchoring the proximal and distal portions 14a, 14 b of the elongate anchor member 14 folded against opposite sidesof the paravalvular leakage 20.

Anchors having two or more elongate anchor members can also be used torepair a paravalvular leakage. Thus, as shown in FIG. 3G, in variousembodiments, an anchor includes a distal elongate anchor member 14 b′, aproximal elongate anchor member 14 a′, and a tensioning member 12slideably connecting the distal elongate anchor member 14 b′ and theproximal elongate anchor member 14 a′. In some embodiments, one end ofthe tensioning member passes through the proximal elongate anchor member14 a′ and the distal elongate anchor member 14 b′, loops back, passesthrough the distal elongate anchor member 14 b′ and the proximalelongate anchor member 14 a′, and forms a knot 16 around the tensioningmember 12. In certain embodiments, the other end, or the proximal end 12a′, of the tensioning member extends through a delivery catheter andexists outside of the body. The passing through an elongate anchormember can be achieved by passing through one or two holes in theelongate anchor member or threading through the elongate anchor memberitself.

Thus, the method of repairing a paravalvular leakage, in someembodiments, includes, as shown in FIG. 3G, inserting the distalelongate anchor member 14 b′ and attached tensioning member 12 through aparavalvular leakage 20. In some embodiments, the method includespulling the proximal end 12 a of the tensioning member 12. The pullingof the tensioning member, in some embodiments, folds at least a portionof the distal elongate anchor member 14 b′ and/or draws the distalelongate anchor member towards the paravalvular leakage site 20, asshown FIG. 3H. In some embodiments, the method includes continuingpulling the proximal end 12 a of the tensioning member 12 to compressthe distal elongate anchor member 14 b′ against the paravalvular leakage20, as shown in FIG. 3I. In some embodiments, the method includesfolding at least a portion of the proximal elongate anchor member 14 a′and drawing the proximal elongate anchor member 14 a′ towards theparavalvular leakage site 20, as shown in FIG. 3J. The folding of atleast a portion of the proximal elongate anchor member 14 a′ and/or thedrawing of the proximal elongate anchor member 14 a′, in certainembodiments, are achieved sequentially or simultaneously by continuingpulling the proximal end 12 a of the tensioning member 12. As the distalelongate anchor member 14 b′ and the proximal elongate anchor member 14a′ are compressed against the paravalvular leakage 20, in someembodiments, the method includes using a suitable locker element 22 tomaintain the anchor 10 in the deployed configuration, as shown in FIG.3L.

FIG. 4 is a side elevation view of an anchor 70 according to someembodiments of the present teachings. This anchor includes a distal tip76. In addition, this anchor includes a proximal radiopaque band 90 anda distal radiopaque band 92. Both the radiopaque bands can be attachedto the suture 72, as shown in FIG. 4, or otherwise secured to the suture72, at the proximal end portion of the anchor member 74 and to eitherthe interior or exterior of the distal tip 76, respectively, or anyother part of the anchor 70. Without wishing to be bound by anyparticular theory, under a fluoroscope, these bands or other markers 90and 92 will indicate to the clinician that the anchor 70 has beendeployed, activated, fully compressed, and/or fastened, as necessaryduring the procedure.

The tip 76 itself may alternatively be formed from a radiopaquematerial. In this embodiment, the knot 94 formed in the suture 72 orother tensioning member is a slip knot through which another portion ofthe suture 72 slides during activation of the anchor 70. It will beappreciated that this slip knot 94 may be replaced by another elementwhich serves substantially or approximately the same purpose but takesthe form, for example, of a small tubular element or other featuresimilar in function to a slip knot.

In various embodiments, the elongate anchor member 74 may be about 40 mmlong by about 3 mm wide. This may be desirable to achieve a lowerprofile. These embodiments may lead to more versatile applications,lower incidents of blood clotting, easier use, etc. Of course, any otherdesired dimensions and shapes may be used, depending on applicationneeds.

As further shown in FIGS. 4 and 6A, the tensioning member or suture 72can advantageously extend through respective fold portions 74 c of theelongate anchor member 74 in essentially an hourglass configuration.Specifically, adjacent portions of the suture 72 located near theproximal and distal end portions 74 a, 74 b of the anchor member 74 arespaced farther apart than the adjacent portions of the suture 72 in themiddle of the anchor member 74.

As further shown in FIG. 6B, radiopaque markers, such as distinct areasof dots 95, may be used for enabling the clinician to visualize thefolds of the elongate anchor member 74 during deployment and securementof the elongate anchor member 74. These dots or other radiopaque markersmay be printed on the anchor member 74. For example, dots 95 or othermarkers may be formed with a platinum powder base ink or other suitablematerial that is radiopaque and biologically compatible. This radiopaquematerial may also add stiffness to the fold sections 74 c therebyhelping to maintain the fold sections 74 c flat and increasing retentionforce on the paravalvular leakage. Meanwhile, the fold lines 74 dbetween fold sections 74 c can remain highly flexible to create tightradius fold lines.

As further shown in FIG. 6A, each of the holes 96 that the tensioningmember or suture 72 is received through may be marked by circles 98surrounding each hole 96 or other markers for visualizing purposesduring assembly of the tensioning member or suture 72 with the elongateanchor member 74. Optionally, holes 96 may be eliminated and the suture72 may be threaded with a needle through the anchor member 74. One couldalso, for example, choose different sets of holes 96 along anchor member74 for receiving the tensioning member or suture 72 thereby changing thewidth of the folds and/or number of folds and/or shape of the foldsdepending on the application needs or desires of the clinician.

The tensioning member or suture 72 may be threaded or otherwise attachedalong the anchor member 74 in any number of manners including, forexample, x-patterns or other crossing patterns, zig-zag patterns, etc.that may alter the folded or otherwise shortened or compressed footprintof the anchor into various beneficial shapes, such as flower shapes,circular shapes or other rounded shapes, ball shapes or otherconfigurations. Modifications of the manner in which the tensioningmember or suture 72 is threaded or otherwise attached along the lengthof anchor member 74 may result in higher or lower tensioning force beingrequired to compress the anchor and/or higher or lower friction holdingforce that may help maintain the anchor in the compressed or shortenedconfiguration.

The width of the elongate anchor member 74′ may be varied along itslength, such as by tapering, stepping, or forming an hourglass shape orshapes along the length of the anchor member 14. For example, asillustrated in FIG. 6C, having proximal and distal end portions 75, 77of wider dimension than an intermediate or middle portion or portions 79along the length of anchor member 74′ will allow these wider portions75, 77 may cover over the more intermediate folded portions 79 andprevent unnecessary contact with adjacent tissue during use.

The elongate anchor member 74 may have variable stiffness including, forexample, a relatively rigid perimeter or relatively rigid edges 74 e, 74f (FIG. 6A) or intermittent relatively rigid sections 74 c″ separated byflexible sections such as living hinges 74 d″ (FIG. 6D) that may aid infolding and securing the elongate anchor member 74″ into a foldedcondition.

FIGS. 5A-5D illustrate a series of steps for deploying and securelyfastening the anchor 70 to a paravalvular leakage site 100 according tosome embodiments of the present teachings. Generally, as shown in FIG.5A, the combination of the elongate anchor member 74 and tensioningmember or suture 72 is deployed through the paravalvular leakage site100. One end or portion 72 a of the suture 72 that extends through theslip knot 94 is then pulled. This causes the distal portion 74 b of theelongate anchor member 74 to fold and compress against the distal sideof the paravalvular leakage 100. As shown in FIG. 5B, further pullingthe tensioning member 72 causes the slip knot 94 to ride upwardly ordistally along the suture 72 and against a proximal portion 74 a of theelongate anchor member 74, thereby folding and compressing the proximalportion 74 a against the proximal side of the paravalvular leakage 100as shown in FIG. 5C. As shown in FIG. 5D, a suitable crimp or lockingelement 102 may be used to securely lock the slip knot 94 in placerelative to the suture or tensioning member segment which extendstherethrough. This will lock the entire anchor 70 in place with therespective proximal and distal folded anchor member portions 74 a, 74 bsecurely retaining the paravalvular leakage 100 therebetween. FIG. 5Dshows the tip 76 acting as a retainer on top of the distal end portion74 b to assist in holding the distal end portion 74 b in place.

FIG. 5E shows an alternative in which the tensioning member is threadedthrough at least one hole 76 a more centrally located in the tip. Yetanother alternative would be to thread the tensioning member through twocentrally located holes instead of through the proximal end of the tip76 and one centrally located hole 76 a as shown in FIG. 5E. Thesealternatives allow the tip 76 to act more like a “T”-bar with forcesacting in a more perpendicular or normal manner relative to the distalend portion 74 b of the anchor member 74.

FIG. 7A illustrates an exemplary anchor of the present teachings. Invarious embodiments, the elongate anchor member has a rectangle profileas illustrated in FIG. 7A. In other embodiments, the elongate anchormember has an hour glass profile as illustrated in FIG. 7B. One skilledin the art would understand that the elongate anchor member can haveother profiles, and accordingly, the embodiments discussed herein arenot limiting to the scope of the present teachings.

Referring to FIG. 7A, an anchor 200 constructed in accordance with someembodiments of the present teachings generally includes a tensioningmember 201 extending from a proximal end portion 212 of an elongateanchor member 210 to a distal end portion 214. In some embodiments, thetensioning member 201 loops back and extends from the distal end 214 tothe proximal end portion 212. In some embodiments, the tensioning member201 passes through a plurality of openings along the elongate anchormember 210. In some embodiments, one end of the tensioning member 201,after it extends from the proximal end to the distal end and loops backto the proximal end of the anchor member 210, forms a knot 220 aroundthe other end portion of the tensioning member 201. In some embodiments,the knot 220 slides along the other end portion of the tensioning member201 in such way that it pulls the free end of the tensioning member 201proximally, causing the knot 220 moving distally and shortening thelongitudinal length of the anchor member 210. By doing so in theseembodiments, the elongate anchor member 210 is folded and the ends ofthe anchor member 210 are drawn toward each other. In certainembodiments, the elongate anchor member 210 also can include at leastone pre-set folding line (not shown) which allows the elongate anchormember 210 to be fold at the pre-set folding line.

In various embodiments, an anchor, such as that referred to as anchor200, shortens at one of the proximal and distal ends. For example, whenthe tensioning member 201 is pulled, at least a part of the distalportion 214 folds first while the proximal end 212 substantiallymaintains its elongated configuration. In some embodiments, this occurswhen the distal portion 214 is deployed. In certain embodiments, thisoccurs when the distal portion 214 is deployed and the proximal portion212 is not deployed, for example, because the proximal portion 212 isrestrained in a delivery catheter (not shown). In other embodiments,when the tensioning member 201 is pulled, at least a part of theproximal portion 212 folds first while the distal portion 214substantially maintains its elongated configuration. It will beappreciated by a person with ordinary skill in the art that an anchor ofthe present teachings may also be folded in a sequential manner underother circumstances.

As seen in FIG. 7A, in various embodiments, the elongate anchor memberhas two sets of openings 225, 226 (first openings 225 and secondopenings 226). In some embodiments, the tensioning member 201 extendsfrom the proximal end portion 212 of the anchor member 210 to the distalend portion 214 of the anchor member 210 through the first set ofopenings 225. Upon reaching the distal end of the elongate anchor member210, in some embodiments, the tensioning member 201 loops back andfurther extends from the distal end portion of the anchor member 210 tothe proximal end of the anchor member through the second set of openings226.

In certain embodiments, as shown in FIG. 7A, the tensioning member 201extends from the proximal end of the anchor member 210 distally, travelsfrom one side of the anchor member 210 to another side by passingthrough the first opening 225 closest to the proximal end of the anchormember 210 in the first set of openings 225; the tensioning member 201further extends distally, passes through the next opening 225 distal tothe first opening 225 in the first set of openings 225. The tensioningmember extends further distally repeating above steps until it passesthrough the last opening 225 in the first set of openings 225 andreaches the distal end of the anchor member 210. In one embodiment ofthe present teachings, there are ten openings 225 in the first set ofopenings 225. Anchor members 210 having between four and twelve openings225 in the first set of openings can be made and used by one withordinary skill in the art without undue experimentation.

In various embodiments of the present teachings, upon reaching thedistal end of the anchor member 210, the tensioning member 201 loopsback, extends proximally, travels from one side of the anchor member 210to another side by passing through the first opening 226 closest to thedistal end of the anchor member 210 in the second set of openings 226.The tensioning member 201 further extends proximally, travels to thefirst side of the anchor member 210 by passing through the next opening226 proximal to the first opening 226 in the second set of openings 226.The tensioning member 201 extends further proximally repeating the abovesteps until it passes through the last opening 226 in the second set ofopenings 226 and reaches the proximal end of the anchor member 210. Insome embodiments of the present teachings, there are ten openings 226 inthe second set of openings 226. Elongate anchor members 210 havingbetween four and twelve openings 226 in this set can be made and used byone with ordinary skill in the art without undue experimentation.

In various embodiments of the present teachings, as illustrated in FIG.7A, the tensioning member 201 extends from one side of the anchor member210 distally, loops back, and ends on the same side of the anchor member210. In other embodiments, the tensioning member 201 extends from oneside of the anchor member 210 distally, loops back, and ends on adifferent side of the anchor member 210.

In various embodiments of the present teachings, the number of openings225 in the first set and the number of openings 226 in the second setare the same as illustrated in FIG. 7A. In other embodiments, the numberof openings 225 in the first set and the number of openings 226 in thesecond set are different.

In some embodiments, the first and second sets of openings 225, 226 aredifferent as illustrated in FIG. 7A. In other embodiments, the first andsecond sets of openings 225, 226 share at least one opening asillustrated in FIG. 7C. This common opening is identified with referencecharacter 227 in FIG. 7C.

As mentioned above, the anchor member 210 can have an hour glass profileas illustrated in FIG. 7B. In this embodiment, the anchor member 210 hasa pair of sections 229 of increased width (with one being located at theproximal end portion 212 and one at the distal end portion 214).

According to various embodiments of the present teachings, at least oneopening 225 in the first set of openings 225 has a corresponding opening226 in the second set of openings 226 and together they form a pair ofopenings on the anchor members 210. In some embodiments, at least onepair of openings 225, 226 form a line perpendicular to the longitudinalaxis of the anchor member 210. In other embodiments, at least one pairof the openings 225, 226 forms a line parallel to the longitudinal axisof the anchor member 210. In yet other embodiments, at least one pair ofthe openings 225, 226 form a line that forms an angle with thelongitudinal axis of the anchor member 210. In some embodiments, linesformed by all of the pairs of openings 225, 226 are in the sameorientation with one another. For example, they can be parallel to oneanother and/or perpendicular to the longitudinal axis of the anchormember 210 as illustrated in FIG. 7A. In another embodiment, they canall be parallel to the longitudinal axis of the anchor member 210. Inyet other embodiments, the lines formed by all the pairs of openings225, 226 can have random directions.

In various embodiments, the two openings 225, 226 in a pair are 2-3 mmapart from each other. In some embodiments, the distance between twoopening 225, 226 is the same in each pair. In some embodiments, thedistance between two openings 225, 226 is different from one pair toanother.

In various embodiments, the distance between two adjacent openings 225,225 (or 226, 226) in the same set, defined by the distance from oneopening to the next closest one in the same set of openings (either 225or 226), is about 5-12 mm. In some embodiments, the distances betweeneach adjacent openings 225, 225 (or 226, 226) is the same as each other.In some embodiments, the distances between each adjacent openings isdifferent from each other.

In various embodiments, at least one pair of the openings 225, 226 areat the lateral center of the anchor member. In some embodiments, all thepairs of openings 225, 226 are at the lateral center of the anchormember. In some embodiments, at least one pair of the openings 225, 226is biased toward one side of the anchor member 210. In some embodiments,all the pairs of openings 225, 226 are biased toward the same side ofthe anchor member. In some embodiments, each of the pairs of openings isbiased toward different sides of the anchor member 210.

In various embodiments, all the openings 225, 226 in at least one set ofopenings, or in both the sets of openings, form a straight line. Invarious embodiments, all the openings in at least one set of theopenings, or in both the sets of openings, form a curved line.

FIG. 8 illustrates an exemplary elongate profile of an exemplary anchor300 that includes an elongate anchor member 310 and wherein the openings225 in the first set of openings 225 form a straight line parallel tothe longitudinal axis of the anchor member 310, and the openings 226 inthe second set of openings 226 form another straight line parallel tothe longitudinal axis of the anchor member 310 and at a distance fromthe line formed by the first set of openings 225.

FIG. 9 illustrates an exemplary elongate profile of an exemplary anchor400 that includes an elongate anchor member 410. The openings 225 in thefirst set of openings form a curve with the openings 225 in the middleportion of the anchor member closest to the lateral center of the anchormember 410, and the openings 226 in the second set of openings formanother curve with the openings 226 in the middle portion of the anchormember 410 closest to the lateral center of the anchor member 410, andthe two curves have a lateral distance from each other and together forman “hour glass” shape.

FIGS. 10A and 10B illustrate an exemplary elongate profile of anexemplary anchor 500 that includes an elongate anchor member 510. Allopenings 225, 226 in both sets of the openings are aligned with eachother forming a straight line parallel to the longitudinal axis of theanchor member 510. FIG. 10B is a side elevation view of the anchormember 510 showing the routing of the tensioning member 201 through theanchor member 510.

In various embodiments, at least one pre-set folding line is createdbetween two pairs of the openings 225, 226, as illustrated in FIG. 12A.The pre-set folding line can be made by heat setting with or without amold. One skilled in the art would understand that other methods canalso be used to create pre-set folding lines without undueexperimentations. In some embodiments, the pre-set folding lines allowthe elongate anchor member to fold at pre-defined places. In certainembodiments, a pre-set folding line is created between every two pairsof the openings 225, 226, for example, as illustrated in FIGS. 8-10.

According to various embodiments of the present teachings, the elongateanchor member (e.g., anchor member 210) shortens and creates folds asillustrated in FIG. 11. In some embodiments, the number of the folds inthe anchor in its deployed profile ranges from 4 to 12. In variousembodiments, the number of the folds is the same as the number of theopenings in at least one set of the openings 225, 226. In otherembodiments, the number of the folds has no particular relationship withthe number of the openings in either set of the openings 225, 226. Invarious embodiments, the number of the folds is the same as the numberof the pre-set folding lines plus one. In other embodiments, the numberof the folds has no particular relationship with the number of thepre-set folding lines.

FIGS. 12A-D illustrate an exemplary embodiment of the present teachings.Specifically, FIGS. 12A and 12D illustrate an exemplary elongate profileand an exemplary deployed profile, respectively, of an anchor 600 of thepresent teachings. The anchor 600 includes an elongate anchor member610. As shown in FIG. 12A, the elongate anchor member 610 has two setsof openings 225, 226 through which the tensioning member 201 weaves. Thetensioning member 201 weaves through the first set of openings 225 as itextends from the proximal end to the distal end of the anchor member 610and weaves through the second set of openings 226 as it returns from thedistal end to the proximal end of the anchor member 610.

In various embodiments of the present teachings, at least one opening inthe first set of openings corresponds with another opening in the secondset of openings and together they form a pair of openings on the anchormember. As shown in FIG. 12A, there are 5 pairs of openings 225, 226 inthe distal portion of the anchor member, and 3 pairs of openings 225,226 in the proximal portion of the anchor member 510. As shown in FIG.12A, each pair of the openings 225, 226 in the distal end section of thedistal portion of the anchor member form an imaginary line and theimaginary lines from the opening pairs 225, 226 in the distal portion ofthe anchor member 610 are parallel to one another and perpendicular tothe longitudinal axis of the anchor member 610, and at the lateralcenter of the anchor member 610; all openings 225, 226 in the proximalend section of the distal portion of the anchor member 610 align withone another and form an imaginary straight line that is parallel to thelongitudinal axis of the entire distal portion of the anchor member 610,and at the lateral center of the entire distal portion of the anchormember 610. Thus, in the proximal portion of the anchor member 610, allopenings 225, 226 from both set of openings align with one another andform an imaginary straight line that is parallel to the longitudinalaxis of the anchor member 610 and at the lateral center of the anchormember 610. One skilled in the art should understand that the amount ofpairs of opening in distal and/or proximal portions of the anchor member610 can be of any number other than what has been described here.

FIG. 12A further illustrates exemplary pre-set folding lines in anelongate anchor member of the present teachings. As shown in FIG. 12A,the folding lines (indicated in the drawings as “L”) in the proximalportions and the distal end portion of the distal portion of the anchormember 610 are parallel to one another and perpendicular to thelongitudinal axis of the anchor member 610. The pre-set folding lines Lbetween the distal end section and proximal end section of the distalportion of the anchor member 610 are angled to the other pre-set foldinglines L. Although specific pre-set folding patterns is shown in FIG.12A, one with ordinary skill in the art would understand that otherpatterns, numbers can be incorporated to form pre-set folding lines L.For example, both the distal and proximal portions of the anchor member610 are parallel to one another and perpendicular to the longitudinalaxis of the anchor member 610, and only a middle portion 615 between thedistal and proximal portions of the anchor member 610 are angled, so asto forming a transitional section across the paravalvular leakage upondeployment. Therefore what is shown in FIG. 12A should not be consideredas being limiting.

FIG. 12A further illustrates an exemplary narrow section in the distalend portion of the anchor member. This narrow section is the result ofradiopaque marker being crimped onto the anchor member. As describedabove, there are other ways of putting one or more radiopaque markersonto the anchor member. Thus, what is shown in this Figure should notlimit the scope of the present teachings.

FIG. 12B illustrates an exemplary deployment profile of an embodiment ofthe present teachings across a paravalvular leakage site. There are 8folds in the deployed anchor as shown in FIG. 12B, among which 5 aredistal to the paravalvular leakage and 3 are proximal to the leakage.One skilled in the art would understand that the number of folds in eachside of the paravalvular leakage should not be viewed as limiting. Asshown in FIG. 12B, the folded panels at the proximal portion of theanchor member and at the proximal end section of the distal portion ofthe anchor member orientate in one direction, and the folded panels inthe distal end portion of the anchor member orientate in anotherdirection that is perpendicular to folded panels in the other direction.The transitional folds between the distal and proximal end section ofthe distal portion of the anchor member are located at the angledpre-set folding line. In this specific embodiment shown in FIG. 12B, thetransitional folds are distal to the paravalvular leakage and aregenerally indicated with the reference character 601 (in other words,the change in folding direction is identified at 601). One skilled inthe art should understand that the transitional folds can be proximal tothe paravalvular leakage, or across the paravalvular leakage, and thuswhat has been illustrated here should not be viewed as limiting.

FIG. 12C is a view of the exemplary anchor shown in FIGS. 12A and B inits deployed configuration. The distal deployed anchor portion has awidth “x” established by the width of the anchor and a length “y”determined by the distance between two pairs of the openings. Theproximal deployed anchor portion has a width “y” established by thedistance between the two pairs of the openings and a length “x”established by the width of the anchor. As shown in this view, theconfiguration in the exemplary embodiment shown in FIGS. 12A-D increasesthe overall width of the deployed anchor. This configuration preventsthe tensioning member from cutting the panel and the paravalvularleakage and increases the retention force of the anchor against theleakage site.

In other words, as shown in FIG. 12D, at least two adjacent anchorpanels 603, 605 are disposed in a crisscrossed manner in that thelongitudinal axes of the adjacent anchor panels 603, 605 are disposedperpendicular to one another as shown.

Other arrangements can be incorporated into the two sets of openings.For example, all the openings from both sets of openings in the distalportion of the anchor member can align with each other to form animaginary straight line that is parallel to the longitudinal axis of theanchor member, and/or each pair of the openings in the proximal portionof the anchor member can form an imaginary line and all the imaginarylines so formed are parallel to one another and perpendicular to thelongitudinal axis of the anchor member. One skilled in the art wouldunderstand that openings in either or both set of the openings can formany configuration so long as it serves the intended purpose.

Although the present teachings have been described with reference topreferred embodiments, persons ordinarily skilled in the art willrecognize that changes can be made in form and detail without departingfrom the spirit and scope of the present disclosure.

1. An apparatus for use at a heart of a subject, the apparatuscomprising: an elongate member, having a longitudinal axis, and havingan elongated configuration in which the elongate member defines: a firstportion that defines a first-portion folding line, substantiallyorthogonal to the longitudinal axis, a second portion that defines asecond-portion folding line, substantially parallel to the first-portionfolding line, and an oblique folding line, longitudinally between thefirst portion and the second portion, the oblique folding line beingnonparallel and nonorthogonal to the longitudinal axis; and a tensioningmember weaving longitudinally along the elongate member such thatapplication of tension to the tensioning member transitions the elongatemember toward a folded configuration by folding: the first portion aboutthe first-portion folding line, the second portion about thesecond-portion folding line, and the elongate member about the obliquefolding line in a manner that positions the first-portion folding linenonparallel to the second-portion folding line.
 2. The apparatusaccording to claim 1, wherein in the folded configuration, thefirst-portion folding line is substantially orthogonal to thesecond-portion folding line.
 3. The apparatus according to claim 1,wherein: the first-portion folding line partitions the first portioninto a first panel and a second panel, and in the folded configuration,the first portion is folded about the first-portion folding line suchthat a surface of the first panel faces a surface of the second panel.4. The apparatus according to claim 3, wherein: the second-portionfolding line partitions the second portion into a third panel and afourth panel, and in the folded configuration, the second portion isfolded about the second-portion folding line such that a surface of thethird panel faces a surface of the fourth panel.
 5. The apparatusaccording to claim 4, wherein, in the folded configuration, the elongatemember is folded about the oblique folding line such that the firstpanel lies transversally across the third panel.
 6. The apparatusaccording to claim 4, wherein: in the elongated configuration, thefirst, second, third, and fourth panels are colinear on the longitudinalaxis, and in the folded configuration: the first and second panels aredisposed in a first rotational orientation that is generally transverseto the longitudinal axis, and the second and third panels are disposedin a second rotational orientation that is generally transverse to thelongitudinal axis, and that is rotationally offset with respect to thefirst rotational orientation.
 7. The apparatus according to claim 1,wherein the elongate member is a first elongate member of a set ofelongate members, the tensioning member weaving longitudinally alongeach of the elongate members of the set, in series.
 8. The apparatusaccording to claim 7, wherein the elongate members of the set arepositionable at the heart of the subject such that application of thetension to the tensioning member reduces a distance between at least twoof the elongate members of the set.
 9. The apparatus according to claim1, wherein the oblique folding line is a first oblique folding line, andwherein the elongate member defines a second oblique folding line,longitudinally between the first portion and the second portion, thesecond oblique folding line being nonparallel and nonorthogonal to thelongitudinal axis, and nonparallel to the first oblique folding line.10. The apparatus according to claim 9, wherein the tensioning memberweaves longitudinally along the elongate member such that application ofthe tension to the tensioning member transitions the elongate membertoward the folded configuration by further folding the elongate memberabout the second oblique folding line.
 11. The apparatus according toclaim 1, wherein the first-portion folding line is a first first-portionfolding line of a plurality of first-portion folding lines defined bythe first portion, each first-portion folding line of the plurality offirst-portion folding lines being substantially orthogonal to thelongitudinal axis.
 12. The apparatus according to claim 11, wherein, inthe folded configuration, the first portion is folded about eachfirst-portion folding line of the plurality of first-portion foldinglines.
 13. The apparatus according to claim 11, wherein, in both theelongated configuration and the folded configuration, the first-portionfolding lines of the plurality of first-portion folding lines aresubstantially parallel to each other.
 14. The apparatus according toclaim 11, wherein the second-portion folding line is a firstsecond-portion folding line of a plurality of second-portion foldinglines defined by the second portion, each second-portion folding line ofthe plurality of second-portion folding lines being substantiallyorthogonal to the longitudinal axis.
 15. The apparatus according toclaim 14, wherein, in both the elongated configuration and the foldedconfiguration, the second-portion folding lines of the plurality ofsecond-portion folding lines are substantially parallel to each other.16. The apparatus according to claim 14, wherein, in the foldedconfiguration, the second portion folded about each second-portionfolding line of the plurality of second-portion folding lines.
 17. Theapparatus according to claim 1, further comprising a catheter, wherein:the elongate member is deliverable, via the catheter, towards the heartin the elongated configuration, the elongate member is positionable atthe heart such that the tensioning member extends, from the elongatemember, through the catheter and out of the subject, and the elongatemember is transitionable towards the folded configuration viaapplication of the tension to the tensioning member from outside of thesubject.
 18. An apparatus for use at a heart of a subject, the apparatuscomprising: an elongate member having an elongated configuration,wherein in the elongated configuration, the elongate member has alongitudinal axis, and defines: a first portion that defines afirst-portion folding line, substantially orthogonal to the longitudinalaxis, the first-portion folding line partitioning the first portion intoa first panel and a second panel, a second portion that defines asecond-portion folding line, substantially parallel to the first-portionfolding line, the second-portion folding line partitioning the secondportion into a third panel and a fourth panel, and an oblique foldingline, longitudinally between the first portion and the second portion,the oblique folding line being nonparallel and nonorthogonal to thelongitudinal axis; and a tensioning member weaving longitudinally alongthe elongate member such that application of tension to the tensioningmember transitions the elongate member toward a folded configuration byfolding: the first portion about the first-portion folding line, suchthat a surface of the first panel faces a surface of the second panel,the second portion about the second-portion folding line, such that asurface of the third panel faces a surface of the fourth panel, and theelongate member about the oblique folding line such that the first panellies transversally across the third panel.